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International Journal of Environmental Research and Public Health
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  • Open Access

8 March 2023

Nurses’ Perceptions of Ethical Conflicts When Caring for Patients with COVID-19

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1
Health Service of Castilla-La Mancha, Integrated Care Management of Talavera de la Reina (Toledo), 45600 Talavera de la Reina, Spain
2
Department of Nursing, Physiotherapy and Occupational Therapy, Faculty of Health Sciences, University of Castilla-La Mancha, Avd/Real Fábrica de Sedas s/n, 45660 Talavera de la Reina, Spain
3
Department of Nursing, Physiotherapy and Occupational Therapy, Faculty of Nursing, University of Castilla-La Mancha, Avd/ Camilo José Cela s/n, 13071 Cuidad Real, Spain
4
Department of Medical-Surgical Therapy, Psychiatry Area, Faculty of Nursing and Occupational Therapy, University of Extremadura, 10003 Caceres, Spain
Int. J. Environ. Res. Public Health2023, 20(6), 4763;https://doi.org/10.3390/ijerph20064763
This article belongs to the Special Issue New Insights into Understudied Phenomena in Healthcare
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Abstract

The COVID-19 pandemic has caused ethical challenges and dilemmas in care decisions colliding with nurses’ ethical values. This study sought to understand the perceptions and ethical conflicts faced by nurses working on the frontline during the first and second waves of the COVID-19 pandemic and the main coping strategies. A qualitative phenomenological study was carried out following Giorgi’s descriptive phenomenological approach. Data were collected through semi-structured interviews until data saturation. The theoretical sample included 14 nurses from inpatient and intensive care units during the first and second waves of the pandemic. An interview script was used to guide the interviews. Data were analyzed following Giorgi’s phenomenological method using Atlas-Ti software. Two themes were identified: (1) ethical conflicts on a personal and professional level; and (2) coping strategies (active and autonomous learning, peer support and teamwork, catharsis, focusing on care, accepting the pandemic as just another work situation, forgetting the bad situations, valuing the positive reinforcement, and humanizing the situation). The strong professional commitment, teamwork, humanization of care, and continuous education have helped nurses to deal with ethical conflicts. It is necessary to address ethical conflicts and provide psychological and emotional support for nurses who have experienced personal and professional ethical conflicts during COVID-19.

1. Introduction

The COVID-19 pandemic has had a dramatic personal and professional impact on health professionals, confronting them with multiple ethical challenges and dilemmas. This involved facing decisions in which important ethical values, principles, or duties conflicted or they had to make mutually inconsistent choices or actions [1]. At times, this involved choosing the “least bad” option [2,3].
At the beginning of the pandemic, ethical conflict and decision-making were influenced by the lack of materials (protective personal equipment (PPE) and respirators) and a shortage of resources—primarily beds and critical care professionals with intensive care unit (ICU) training [4].
Nurses who have been on the “front line” have perceived morally distressing situations or ethical dilemmas, such as the inability to provide adequate care, the provision of care in unsafe conditions, the lack of access to health care and to health care services [5,6], scarce resources, a high risk of infection, and concern about infecting their families; inadequate working conditions and rapid changes in workflow; a lack of specific skills and competences, fear of uncertainty, and frustration; and social stigmatization, isolation, and a lack of social support [6,7,8].
In this context, nurses encountered new tensions related to traditional ethical principles: social justice versus individual patient autonomy or beneficence versus public health non-maleficence [9]. The inability to involve patients and their families in decisions about their process and to accompany their patients in their suffering was a major source of ethical conflict [4]. Furthermore, the ineffectiveness of initial treatments, the “try anything and everything” strategy, and the use of age as a criterion for not admitting patients to the ICU (i.e., prioritizing resources for patients with a higher survival rate) also caused moral distress [4].
In addition, the situations experienced clashed with the core values and virtues attributed to nurses and with what is set out in their codes of ethics (humanity, compassion, benevolence, personal and professional competence, ethical practice, and moral rectitude) [10].
It is known that the psychological and emotional responses associated with discomfort or moral distress from ethically wrong actions can increase sometime after the situation [11,12]. These responses include feelings of helplessness, self-blame, anger, frustration, exhaustion, anxiety, and depression [13,14,15]; deterioration in the quality of care and teamwork; and the desire to quit the job [16]. The COVID-19 pandemic has been one of the most significant challenges faced by health workers, provoking intense negative emotional responses [16].
This study aimed to understand the perceptions and ethical conflicts faced by nurses working on the frontline during the first and second waves of the COVID-19 pandemic and the main coping strategies they used to resolve these conflicts.

2. Methods

2.1. Design and Participants

A qualitative study was designed and analyzed using Giorgi’s descriptive phenomenological approach, which discovers the meaning of a phenomenon through the identification of fundamental themes [17]. This approach was chosen to describe the experiences of nurses caring for people with COVID-19 during the first two waves of the COVID-19 pandemic and the ethical dilemmas from the nurses’ experience through a phenomenological analysis of (and in) their own words [18]. This study followed the recommendations of the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [19].
This study used a theoretical sample of nurses who cared for people admitted with COVID-19 during the first and second waves of the pandemic in public hospitals of the regions of Madrid and Extremadura. These two regions were chosen because they were among the most affected during the first two waves.
The inclusion criteria were as follows: (1) nurses who had worked for more than two months in active duty during these two waves of the pandemic caring for patients suffering from COVID-19; (2) nurses working in hospital units or intensive care units. The exclusion criterion was as follows: (1) nurses who had worked for less than two months with COVID-19 patients. The socio-demographic characteristics and characteristics related to educational level and employment of the participants are shown in Table 1.
Table 1. Main characteristics of participants (N = 14).
Semi-structured interviews conducted between May and December 2020 were used for data collection to include nurses’ experiences of the first two waves of the COVID-19 pandemic. Interviews lasted an average of 66 min (range 36–116 min). Semi-structured interviews were chosen for their ability to provide a “naïve description” of this psychological phenomenon in the participants’ own words [18,20].

2.2. Data Collection and Data Sources

Data collection and analysis were carried out simultaneously following the constant comparison method. Data collection continued until data saturation, at which point additional input (new codes, categories, or subcategories) from new participants no longer provides new information [21].
The interviews were conducted in a comfortable, private location agreed upon with the participant by the main researcher (blinded for review), who had a script of topics that could appear openly during the interview (Table 2) [20]. The interview script of topics was refined throughout the study, following the constant comparison method, with the information that emerged in each interview. The interviewer was an expert in qualitative research and had extensive experience in the semi-structured interview technique. He has a background in Public Health and no clinical experience in the study field. The position of the interviewer is a strength of this study, which prevented the interviewer from knowing too much about the phenomenon under study. Moreover, none of the authors knew the participants. Most of the interviews were conducted face-to-face; however, due to the evolution of the pandemic, four participants preferred to conduct the interview via videoconference.
Table 2. Interview topic script.

2.3. Data Analysis

Once transcribed and anonymized, the interviews were analyzed following Giorgi’s phenomenological method: (1) collecting and describing phenomenological data, (2) reading the entire description, (3) breaking descriptions into meaning units, (4) transforming meaning units, (5) identifying the essential structure of the phenomenon, and (6) integrating features into the essential structure of the phenomenon. Theoretical reflective writing was used during the analysis process [17].
The data analysis was carried out independently by two researchers, who subsequently reached a consensus on the results; in the event of a disagreement, a third researcher was used. The research team examined the codes and themes to formulate the categories and final themes. Atlas-ti 8.0 software was used to assist in this phase.

2.4. Trustworthiness

The criteria of credibility, transferability, dependability, and confirmability were used to establish study trustworthiness [22]. Various strategies have been developed to ensure credibility, such as the following: reflexivity (all researchers had a constant reflective attitude attending to methodological crossroads decision-making and interpretative issues), research triangulation (comparison and discussion between two different researchers during the analytical process; in the case of discrepancy, a third investigator was called upon to resolve the discrepancies), and return to interviewees (during the last interviews, as themes were becoming saturated, new questions were introduced in interviews to confirm the intersubjective experience interpretation; in addition, the transcripts of the interviews were returned to the participants to check their agreement). In relation with confirmability, along this manuscript, we have tried to be very transparent with our research process for other researchers to know what stages and how we have to cope with different tasks and difficulties. Finally, in terms of helping the audience to assess the transferability of results, we have meticulously described the participant characteristics that condition their experience, as well as the environment where the research was conducted.

3. Results

Table 1 shows the main characteristics of the 14 nurse participants. During the first and second waves of the COVID-19 pandemic in Spain, the nurses working in hospital units or intensive care units faced significant ethical conflicts, identifying two main themes: (1) ethical conflicts experienced during the pandemic on a personal and professional level and (2) coping strategies used to deal with ethical conflicts (active and autonomous learning, peer support and teamwork, moments of emotional catharsis, focusing on care, accepting the pandemic as just another work situation, forgetting bad situations experienced, valuing positive reinforcement from patients, relatives, and society, and humanizing the situation). Table 3 and Table 4 show the categories, codes, and selection of the main verbalizations for each of the emerging themes. The verbalizations are accompanied by the code of each interview, which identifies the interview number, the gender (F: female and M: male), and age of the participant.
Table 3. Categories, codes, and verbalizations of Theme 1: Ethical conflicts experienced during the pandemic.
Table 4. Categories, codes, and verbalizations for Theme 2: Coping strategies for ethical conflicts experienced during the pandemic.

3.1. Theme 1. Ethical Conflicts during the Pandemic

The nurses faced ethically demanding situations and ethical conflicts arising from a lack of knowledge, information, action protocols, staff, or protective materials. These ethical conflicts arose in both their personal and professional lives (Table 3).

3.2. Ethical Conflicts at the Personal Level

Faced with the fear of infecting their family members and the fear of the contagion, most nurses made significant changes to their personal lives, including modifying their family routines and personal behaviors, voluntarily isolating themselves from family and friends, and living with other health professionals as protective measures. In addition, at the onset of the pandemic, nurses sacrificed their personal lives in order to practice their profession full time, which sometimes led to family conflicts when their relatives asked them to leave their jobs.

3.3. Ethical Conflicts at the Professional Level

The ethical conflicts that stood out at the beginning were those related to moral suffering, the perception of risking personal integrity and life, the wrongful death of patients, and the neglect of patients’ basic rights.

3.3.1. Moral Suffering

The nurses experienced moral distress due to external factors that prevented them from providing the care they considered ethically correct.

3.3.2. Endangering Their Personal Integrity and Their Lives

The nurses continued to provide care, despite the absence of protective equipment, working with non-approved equipment or not knowing what they were dealing with, which could put their right to personal integrity and their own lives at risk for the benefit of the general population, thus exceeding the obligations of a nurse according to the legislation in force and the code of ethics.
In addition, they highlighted the conflicts that arose with their superiors over certain orders that put their health at risk, for example, the recommendation not to wear masks during the early days of the pandemic so as to avoid being disconcerting patients.

3.3.3. Poor Patient Death

One of the aspects that most marked the nurses at the beginning of the pandemic was the “bad death” or “poor death” experiences of the patients, due to the rapid decompensation they suffered and dying in solitude. The solitude faced by patients occurred not only because family visits were prohibited, but also because the work saturation meant that when they returned from making the rounds of the rooms, some patients had died, often showing signs that they had done so in distressful situations (this included facial gestures, patients who had fallen on the floor after getting out of bed, etc.).

3.3.4. Neglect of Basic Patient Rights

The nurses highlighted the neglect of basic patient rights related to autonomy, beneficence, and justice.
Autonomy
On certain occasions, nurses did not respect the principle of patient autonomy in order to protect community health, for example, by using physical restraints on people with intellectual disabilities to prevent them from leaving the room, in this case taking precedence over the community good.
Beneficence
Especially at the beginning of the pandemic, despite the effort to do everything possible with the knowledge they had available, nurses noted the rapid deterioration of patients and the high death rates. This provoked intense feelings of frustration and helplessness in the nurses. On other occasions, the nurses acknowledged a sense of guilt and questioned whether they could have done more to save the patient.
In these initial phases, the nurses’ questioned the care provided due to a lack of knowledge of the virus, lack of effective protocols, fear of the contagion, and lack of materials. They considered that the care provided was not the most appropriate or did not provide all the support and comfort to the patients.
Moreover, especially in the early stages, nurses had to care for patients with COVID-19 without adequate protective measures to protect themselves or other patients from infection.
The nurses acknowledged that on certain occasions, the information provided to relatives was concealed or embellished on the recommendation of their superiors, believing that this would save them suffering; although this lack of honesty made them feel like impostors.
Justice
In the initial phases, the principle of justice was affected by limited resources and by the need to prioritize care for COVID-19 patients and treatments. Furthermore, in many cases, the protocols were unclear. The nurses emphasized that limited resources and the large number of patients requiring such resources made the criteria for admission to ICU beds very restrictive. Among the criteria for prioritization, in the early phases of the pandemic, age was used, with young patients being prioritized over older patients. Moreover, in the early phases of the pandemic, patients with COVID-19 were considered non-reuscitable, and therefore sometimes died of other diseases, such as cardiac pathologies, without nurses being able to attempt cardiac resuscitation. Moreover, nurses noted that routine care was often delayed or curtailed to redistribute scarce resources at the onset of the pandemic.
In addition, the nurses themselves perceived that they had suffered from this inequity in access to protective equipment between different hospital units and even between different professional categories within the same unit. Thus, nurses reported that physicians had access to better protective equipment than themselves, even though nurses cared for patients at their bedside 24 h a day.
Also noteworthy was the perceived lack of solidarity among the nurses themselves, since they did not share the material and kept it locked away to avoid others using it, when previously it had always been shared among different units and professionals.
In addition, they perceived an inequal exposure to the virus among doctors and nurses, since nurses spent more time in an infectious environment, indeed, they cared for patients 24 h a day, and the care techniques they performed were more invasive and riskier. In the early stages of the pandemic, the nurses considered that physicians delegated upon nurses’ actions outside their scope of competence, such as the responsibility of assessing patients to prevent them from entering rooms and taking risks. In addition, nurses perceived that their professional relationships with physicians changed during the pandemic, with contact, visiting times, and meetings decreasing due to physicians’ fear of the contagion. In addition, according to the nurses, physicians in some specialties were allowed to telework.
Finally, the nurses felt that the healthcare system had failed because of the lack of resources for themselves and patients to be treated with equity and fairness.

3.4. Theme 2. Coping Styles for Dealing with Ethical Conflicts

Faced with the above ethical conflicts, the nurses used the following coping strategies.

3.4.1. Autonomous Active Learning or Learning among Peers

Due to the lack of information and training in the institutions where they worked, the nurses used active autonomous learning and peer learning. In addition, the lack of institutional protocols, especially at the beginning of the pandemic, led them to develop their own protocols, which they modified as the situation changed.
As self-training resources, they used social networks, such as YouTube, Twitter, WhatsApp groups, or internet resources, specifically to learn novel techniques or in cases where they had to urgently start working in a new unit. This self-training was conducted by the nurses in their free time or outside of their workday.

3.4.2. Peer Support and Teamwork

To deal with ethical conflicts, nurses considered peer emotional support and teamwork essential, including nurses and nursing care technicians within the nursing team.
Regarding teamwork, the nurses highlighted the trust they had in the team members, perceiving it to be greater than they had ever experienced and how this support could continue outside the working day through telephone conversations or WhatsApp groups, which were conceptualized as an outlet to share the experiences and problems they were experiencing, since on many occasions, they did not want to worry their own family.

3.4.3. Moments of Catharsis and Disconnection through Humor, Music, or Dance

As an escape from the difficult situations they endured, the nurses used a sense of humor, music, or choreographed dances with other colleagues at specific moments of their working day. The nurses emphasized that these were only occasional moments of the working day and that they had nothing to do with the frivolous image of dances that the media have conveyed in Spain, which is far removed from the reality experienced by the nurses during the pandemic.

3.4.4. Staying Focused

At the beginning of the pandemic, the work environment did not help the nurses due to chaos, disorganization, and the lack of information, protocols, and protective equipment. Moreover, during this initial chaos, the nurses felt a lack of support from their superiors (nursing supervisors, hospital management, health administration, etc.), which meant that they had to resolve the conflicts that arose as best they could. Faced with this situation, the nurses focused on care and on the problems that arose at any given moment as coping strategies.

3.4.5. Accepting the Pandemic as a Work Situation

Nurses perceived the pandemic as a work situation that they had to endure, something historic and which they had to face as their duty and professional commitment.

3.4.6. Forgetting the Bad Situations That Had Occurred

A protective mechanism in situations of post-traumatic stress was dissociative amnesia (forgetting moments with a high negative emotional charge), trying to forget the bad moments experienced.

3.4.7. Valuing the Positive Reinforcement of Patients, Their Families, and Society

The gratitude and positive reinforcement received from patients, their families, and society, helped them cope with the difficulties and gave them encouragement during the first wave of the pandemic, perceiving that society valued their efforts and the risk they were exposing themselves to in order to care for others.
A notable occurrence in Spain during the confinement was that every day at eight o’clock in the evening, people spontaneously went out to their windows to applaud health professionals and other first responders. According to the nurses’ speeches, this applause helped them to cope with the tough working situations they were experiencing, although at the same time, they demanded that this support be translated into real improvements in their working conditions and in healthcare at large.

3.4.8. Humanizing the Situation

Faced with the harshness of the situation and the violation of patients’ rights on multiple occasions, the nurses tried to humanize care as much as possible. They spent time during their working days, and often outside of them, making phone and video calls with relatives. In addition, as more information was known about the virus, the nurses tried to allow the families to say goodbye to their family member by allowing them quick visits for which they provided them with PPE that they did not have to spare at the time.

4. Discussion

This study analyzes the ethical and moral concerns and ethical conflicts experienced by nurses during the COVID-19 pandemic. Two main themes emerged: the ethical conflicts experienced on a personal and professional level; and the main coping strategies used by nurses to deal with these conflicts: learning; support and teamwork; catharsis and disengagement; focusing on care and everyday work; acceptance of the pandemic; “forgetting”; social positive reinforcement; and humanizing care.
The setting in which the study took place is a COVID-19 care unit (ward or ICU), which is similar to the setting of many other studies worldwide [23]. In our case, data saturation was reached with 14 nurses, but other studies present a lower sample size (seven nurses) [23].

4.1. Theme 1: Ethical Conflicts during the Pandemic

In line with previous studies, the first-line nurses decided, voluntarily and in agreement with their relatives, to adopt measures to protect them from the possible contagion, such as isolating themselves from their relatives at home, living in other places or with colleagues, or modifying family routines (shower on arrival at home, extra washing of clothes, etc.) [16,24,25,26]. This is a source of family conflict and increases the nurses’ emotional burden and feelings of isolation and loneliness [8,27,28].
In addition, the pandemic situation, uncertainty, fear, and lack of protection in some instances led nurses to consider a temporary career break or request sick leave [25,26]. However, nurses showed moral courage, understood as the determination to stand firm to do what is ethical when doing the right thing is not easy, an ethical virtue that helps someone overcome physical or emotional obstacles to act on what is believed to be the right thing [18,29,30,31]. In this manner, most nurses decided to fulfill their duty and obligation of care to patients with COVID-19 despite fear [16,30,31]. Other reasons given that follow the line of previous studies include the deep-rooted professional commitment, nurses’ strong vocation, their personal values, or their commitment to society [25,26,32].
Our participants accepted the pandemic as just another work situation they had to face, coping with and assuming responsibility for the care of people with COVID-19. Nurses have reported feelings of pride, considering that they are better professionals after having experienced this situation [16]. This result can be explained by the fact that, despite the changing clinical context during the first waves, they were able to adapt quickly to the changes and to the new way of working [25,31].
As other studies have already shown, the moral suffering of nurses during this pandemic is remarkable and increases as the pandemic progresses, with loneliness and the isolation of patients and families acting as aggravating factors, or the prioritization of resources due to the scarcity of ventilatory support, personal protective equipment (PPE), ICU beds, etc., which put the personal integrity of the nurses at risk [4,33,34].
Another highly traumatic fact was the elevated number of deaths and the circumstances in which they occurred, conceptualized by the nurses as “poor deaths”, not only because patients had to die alone, without family members and without traditional end-of-life practices, but also because of how these deaths sometimes occurred (shortage of ventilators, cardio pulmonary resuscitation was not performed, etc.), causing extra moral suffering to the nurses [16,28,31,35].
Moreover, nurses considered that despite doing everything possible to save the patient’s life or to provide excellent quality and ethical care, the pandemic situation prevented them from providing care as they would have liked [8,9,36]; this generates feelings of frustration and helplessness, considering that the situation became unsustainable [16,35]. In addition, they sometimes felt guilty about the care provided, which can be detrimental to their mental health and cause added moral damage [4,8,31].
Nurses highlighted the violation of the fundamental ethical principle of justice as the pandemic forced the values of autonomy and beneficence to yield to justice [9]. The shortage of material resources (ventilators, ICU beds, etc.,) is considered by nurses to be a major ethical burden, having to face situations in which they knew the ethically correct actions, but were unable to perform them. This led to decisions that generated moral or ethical discomfort, due to inequity in the access to resources and treatments (respirators, ICU, or Intermediate Respiratory Care Unit (IRCU) beds, etc.) [25,35,37,38,39]. The pandemic led to a significant increase in the volume and intensity of work, which undermined equity in access to resources and treatment [9,25,40]. Consequently, complaints from healthcare professionals about the lack of protective gear have been universal [25].
Thus, the nurses reported having to buy their own equipment at times or having to behave in an unsupportive manner towards colleagues from other units by not lending them protective materials [9]. Faced with this situation, nurses have highlighted the insufficient institutional support or negligence in protection of staff [25,35].
Other studies highlight the inequality in the exposure to the virus, showing that nurses have been more exposed to the virus than any other healthcare profession [9,15,27]. The pandemic situation caused them to assume the functions of other professionals (physicians, technicians, etc.), increasing their responsibility and feelings of isolation [16,31]. In addition, this was perceived as a complete lack of respect and consideration for the nurse as an expendable person [16,27].
In addition, the fact that family members could not accompany the patient during admission meant that nurses facilitated communication between patients and family members through video calls, which meant an overload of work and an emotional and moral burden since they became witnesses to conversations and farewells that were previously done behind closed doors [9,16,30,41]. This situation provoked another novel ethical conflict, such as the communication of death via telephone to the relative, and how, applying the principle of beneficence, the nurses tried to relieve suffering of the relatives and therefore softened the information provided about the patient’s death so that they would have a better memory of the time or less grief, and this “white lie”, which was said out of compassion, made them have second thoughts, although it was relieving them to think that they were doing so to avoid suffering.

4.2. Theme 2: Coping Styles for Dealing with Ethical Conflicts

The COVID-19 pandemic was characterized by real-time experience and rapid and constant changes, including contradictory messages from government agencies that exacerbated fear and mistrust and difficulties keeping up with the pandemic [31]. Nurses were concerned about their training on an ongoing basis and, especially outside working hours, attempted to update their training through social networks and protocols sent by hospital managements [7,16,25]. This continuous learning has led to changes in the organization of care to make it more efficient and safe [18,33]; this shows that, as nurses became more familiar with the care of the disease, the emotional burden and fear decreased [25,32].
The nurses considered it very positive to feel the emotional support and trust between colleagues, and they emphasized that teamwork is vital to survive this situation and avoid negative emotions, where this support continued outside the working day [16,27,31,42].
In addition, many nurses faced the situation with a positive attitude, allowing them to reinterpret the negative situations experienced [43,44]. They emphasized that they did not regret having chosen the profession, accepting this situation as part of being a nurse and the duty of care [25]. Another strategy to reduce anxiety levels was the use of humor [45,46], in what they called catharsis, although they complained about how the media or the public sometimes misinterpreted these venting behaviors.
Disengagement and venting represent dysfunctional or unhealthy coping behaviors, such as denial, avoidance, or giving up [47], and are used in stressful situations [48]. These strategies of emotional disengagement and venting behaviors have been observed in other studies to ease mental discomfort [49].
However, another study describes unhealthy coping, such as substance abuse, suppression of their feelings, “burying the trauma” (forgetting this bad experience), and emotional detachment [16].
Another key aspect was to feel the support of patients, family members, and the community [16].

4.3. Limitations and Strengths

Among the strengths of this study, we analyzed the first and second waves of the pandemic, which were moments of great uncertainty and a lack of knowledge, in which ethical conflicts were more novel and prominent. In addition, the study included participants from various autonomous communities of Spain, based on different units and training, professional experience, and sociodemographic characteristics. The reviewed studies address ethical dilemmas; however, few studies refer to nurses’ coping strategies.

5. Conclusions

Nurses have experienced ethical conflicts on a personal and professional level and have strived to optimize and deliver safe and ethical care to patients with COVID-19 even when their lives were at risk. The main coping strategies used by nurses to deal with these conflicts have been active and autonomous learning, peer support and teamwork, moments of emotional catharsis, focusing on care, accepting the pandemic as just another work situation, forgetting bad situations experienced, valuing positive reinforcement from patients, relatives, and society, and humanizing the situation. Strong professional duty and commitment, teamwork, humanization of care, and continuing education have helped nurses cope with such conflicts. Ethical concerns and conflicts that arose along with work overload and other factors may have contributed to increased psychological distress among frontline nurses.
Future studies should analyze ethical conflicts arising in the context of primary care and social and health care. In addition, it would be useful to know which interventions would lead to improvements in the coping strategies used by nurses during ethical conflicts.

Implications for Nursing Management

Ethical concerns and conflicts that arose along with work overload and other factors may have contributed to the increase in psychological distress among frontline nurses. It is necessary to address ethical conflicts and provide psychological and emotional support programs to those nurses who have experienced personal and professional ethical conflicts when trying to optimize and provide safe and ethical care during COVID-19.

Author Contributions

Conceptualization, F.L.-E., B.R.-M., P.Á.C.-A. and J.R.-A.; methodology, F.L.-E., J.R.-A., B.R.-M. and P.Á.C.-A.; software and formal analysis, F.L.-E., J.R.-A., P.Á.C.-A. and B.R.-M.; investigation, resources, writing—original draft preparation and writing—review and editing, F.L.-E., B.R.-M., P.Á.C.-A., J.R.-A., C.C.-L., C.R.-B., I.C.N. and A.H.-M. All authors have read and agreed to the published version of the manuscript.

Funding

This work was sponsored by the University of Castilla-La Mancha (GRANT 2021-GRIN-31074).

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and the data protection law. This study was approved by the Ethics Committee of the Hospital of Cáceres (Ref: CEIM20/278). It has been developed following the commonly accepted ethical principles in biomedical research with human beings: respect for the person or autonomy, non-maleficence, beneficence, and justice. Anonymity and privacy of the individual results were guaranteed, and the pregnant women were invited to participate and answer the survey and perform the examination voluntarily, applying informed consent. All patients were informed of the process in detail and decided to take part in the project of their own free will. To this end, they signed an informed consent form. The voluntary nature of participation in the study was guaranteed, as well as the confidentiality of the data extracted.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Acknowledgments

All participants.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Deschenes, S.; Gagnon, M.; Park, T.; Kunyk, D. Moral distress: A concept clarification. Nurs. Ethics 2020, 27, 1127–1146. [Google Scholar] [CrossRef]
  2. Jia, Y.; Chen, O.; Xiao, Z.; Xiao, J.; Bian, J.; Jia, H. Nurses’ ethical challenges caring for people with COVID-19: A qualitative study. Nurs. Ethics 2021, 28, 33–45. [Google Scholar] [CrossRef] [PubMed]
  3. O’Mathúna, D. Ideal and nonideal moral theory for disaster bioethics. Hum. Aff. 2016, 26, 8–17. [Google Scholar] [CrossRef]
  4. Riedel, P.L.; Kreh, A.; Kulcar, V.; Lieber, A.; Juen, B. A Scoping Review of Moral Stressors, Moral Distress and Moral Injury in Healthcare Workers during COVID-19. Int. J. Environ. Res. Public Health 2022, 19, 1666. [Google Scholar] [CrossRef]
  5. Norful, A.A.; Rosenfeld, A.; Schroeder, K.; Travers, J.L.; Aliyu, S. Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States. Gen. Hosp. Psychiatry 2021, 69, 20–26. [Google Scholar] [CrossRef] [PubMed]
  6. Santolalla-Arnedo, I.; del Pozo-Herce, P.; de Viñaspre-Hernandez, R.R.; Gea-Caballero, V.; Juarez-Vela, R.; Gil-Fernandez, G.; Garrido-Garcia, R.; Echaniz-Serrano, E.; Czapla, M.; Rodriguez-Velasco, F.J. Psychological impact on care professionals due to the SARS-CoV-2 virus in Spain. Int. Nurs. Rev. 2022, 69, 520–528. [Google Scholar] [CrossRef] [PubMed]
  7. O’Reilly-Jacob, M.; Perloff, J.; Sherafat-Kazemzadeh, R.; Flanagan, J. Nurse practitioners’ perception of temporary full practice authority during a COVID-19 surge: A qualitative study. Int. J. Nurs. Stud. 2022, 126, 104141. [Google Scholar] [CrossRef]
  8. Muz, G.; Erdoğan Yüce, G. Experiences of nurses caring for patients with COVID-19 in Turkey: A phenomenological enquiry. J. Nurs. Manag. 2021, 29, 1026–1035. [Google Scholar] [CrossRef]
  9. Ben-Jacob, T.K.; Peterson, L.K.N. Drastic changes in the practice of end-of-life care during the COVID-19 pandemic. J. Crit. Care 2022, 67, 195–197. [Google Scholar] [CrossRef]
  10. American Nursing Association (ANA). Nurses, Ethics and the Response to the COVID-19 Pandemic. Amercian Nurses Association. 2020. Available online: https://www.nursingworld.org/~4981cc/globalassets/covid19/nurses-ethics-and-the-response-to-the-covid-19-pandemic_pdf-1.pdf (accessed on 1 February 2021).
  11. Gingell Eipstein, E.; Baile Hamric, A. Moral distress, moral residue, and the crescendo effect. J. Clin. Ethics 2009, 20, 330–342. [Google Scholar] [CrossRef]
  12. Saragih, I.D.; Tonapa, S.I.; Saragih, I.S.; Advani, S.; Batubara, S.O.; Suarilah, I.; Lin, C.J. Global prevalence of mental health problems among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Int. J. Nurs. Stud. 2021, 121, 104002. [Google Scholar] [CrossRef] [PubMed]
  13. Dragioti, E.; Tsartsalis, D.; Mentis, M.; Mantzoukas, S.; Gouva, M. Impact of the COVID-19 pandemic on the mental health of hospital staff: An umbrella review of 44 meta-analyses. Int. J. Nurs. Stud. 2022, 131, 104272. [Google Scholar] [CrossRef] [PubMed]
  14. Rodney, P.A. What We Know About Moral Distress. Am. J. Nurs. 2017, 117 (Suppl. S1), S7–S10. [Google Scholar] [CrossRef] [PubMed]
  15. Squires, A.; Clark-Cutaia, M.; Henderson, M.D.; Arneson, G.; Resnik, P. “Should I stay or should I go?” Nurses’ perspectives about working during the COVID-19 pandemic’s first wave in the United States: A summative content analysis combined with topic modeling. Int. J. Nurs. Stud. 2022, 131, 104256. [Google Scholar] [CrossRef] [PubMed]
  16. Kelley, M.M.; Zadvinskis, I.; Miller, P.S.; Monturo, C.; Norful, A.A.; O’Mathúna, D.; Roberts, H.; Smith, J.; Tucker, S.; Zellefrow, C.; et al. United States nurses’ experiences during the COVID-19 pandemic: A grounded theory. J. Clin. Nurs. 2022, 31, 2167–2180. [Google Scholar] [CrossRef]
  17. Giorgi, A. The Descriptive Phenomenological Method in Psychology: A Modified Husserlian Approach; Duquesne University Press: Pittsburgh, PA, USA, 2012. [Google Scholar]
  18. The SAGE Handbook of Qualitative Research in Psychology|SAGE Publications Ltd. Available online: https://uk.sagepub.com/en-gb/eur/the-sage-handbook-of-qualitative-research-in-psychology/book245472 (accessed on 13 July 2022).
  19. Tong, A.; Sainsbury, P.; Craig, J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int. J. Qual. Health Care 2007, 19, 349–357. [Google Scholar] [CrossRef] [PubMed]
  20. Englander, M. The Interview: Data Collection in Descriptive Phenomenological Human Scientific Research. J. Phenomenol. Psychol. 2012, 43, 13–35. [Google Scholar] [CrossRef]
  21. Saunders, B.; Sim, J.; Kingstone, T.; Baker, S.; Waterfield, J.; Bartlam, B.; Burroughs, H.; Jinks, C. Saturation in qualitative research: Exploring its conceptualization and operationalization. Qual. Quant. 2018, 52, 1893–1907. [Google Scholar] [CrossRef]
  22. Guba, E.G.; Lincoln, Y.S. Fourth Generation Evaluation; Sage: London, UK, 1989; p. 294. [Google Scholar]
  23. Alwesmi, M.B.; Dator, W.L.; Karavasileiadou, S. Lived Experiences of Female Nurses with COVID-19 Deaths on Their Watch. Behav. Sci. 2022, 12, 470. [Google Scholar] [CrossRef]
  24. Silverman, H.J.; Kheirbek, R.E.; Moscou-Jackson, G.; Day, J. Moral distress in nurses caring for patients with COVID-19. Nurs Ethics 2021, 28, 1137–1164. [Google Scholar] [CrossRef]
  25. Sperling, D. Ethical dilemmas, perceived risk, and motivation among nurses during the COVID-19 pandemic. Nurs. Ethics 2021, 28, 9–22. [Google Scholar] [CrossRef] [PubMed]
  26. Lake, E.T.; Narva, A.M.; Holland, S.; Smith, J.G.; Cramer, E.; Rosenbaum, K.E.F.; French, R.; Clark, R.R.; Rogowski, J.A. Hospital nurses’ moral distress and mental health during COVID-19. J. Adv. Nurs. 2022, 78, 799–809. [Google Scholar] [CrossRef] [PubMed]
  27. George, C.E.; Inbaraj, L.R.; Rajukutty, S.; de Witte, L.P. Challenges, experience and coping of health professionals in delivering healthcare in an urban slum in India during the first 40 days of COVID-19 crisis: A mixed method study. BMJ Open 2020, 10, e042171. [Google Scholar] [CrossRef]
  28. Joo, J.Y.; Liu, M.F. Nurses’ barriers to caring for patients with COVID-19: A qualitative systematic review. Int. Nurs. Rev. 2021, 68, 202–213. [Google Scholar] [CrossRef] [PubMed]
  29. Numminen, O.; Repo, H.; Leino-Kilpi, H. Moral courage in nursing: A concept analysis. Nurs. Ethics 2017, 24, 878–891. [Google Scholar] [CrossRef] [PubMed]
  30. Peter, E.; Mohammed, S.; Killackey, T.; MacIver, J.; Variath, C. Nurses’ experiences of ethical responsibilities of care during the COVID-19 pandemic. Nurs. Ethics 2022, 29, 844–857. [Google Scholar] [CrossRef] [PubMed]
  31. Schroeder, K.; Norful, A.A.; Travers, J.; Aliyu, S. Nursing perspectives on care delivery during the early stages of the COVID-19 pandemic: A qualitative study. Int. J. Nurs. Stud. Adv. 2020, 2, 100006. [Google Scholar] [CrossRef]
  32. Iserson, K.v. Healthcare Ethics During a Pandemic. West J. Emerg. Med. 2020, 21, 477–483. [Google Scholar] [CrossRef]
  33. Kanaris, C. Moral distress in the intensive care unit during the pandemic: The burden of dying alone. Intensive Care Med. 2021, 47, 141–143. [Google Scholar] [CrossRef]
  34. Sheather, J.; Fidler, H. COVID-19 has amplified moral distress in medicine. BMJ 2021, 372, n28. [Google Scholar] [CrossRef]
  35. Romero-García, M.; Delgado-Hito, P.; Gálvez-Herrer, M.; Ángel-Sesmero, J.A.; Velasco-Sanz, T.R.; Benito-Aracil, L.; Heras-La Calle, G. Moral distress, emotional impact and coping in intensive care unit staff during the outbreak of COVID-19. Intensive Crit. Care Nurs. 2022, 70, 103206. [Google Scholar] [CrossRef] [PubMed]
  36. Thapa, S.B.; Kakar, T.S.; Mayer, C.; Khanal, D. Clinical Outcomes of In-Hospital Cardiac Arrest in COVID-19. JAMA Intern. Med. 2021, 181, 279–281. [Google Scholar] [CrossRef]
  37. Emanuel, E.J.; Persad, G.; Upshur, R.; Thome, B.; Parker, M.; Glickman, A.; Zhang, C.; Boyle, C.; Smith, M.; Phillips, J.P. Fair Allocation of Scarce Medical Resources in the Time of COVID-19. N. Engl. J. Med. 2020, 382, 2049–2055. [Google Scholar] [CrossRef]
  38. Mo, Y.; Deng, L.; Zhang, L.; Lang, Q.; Liao, C.; Wang, N.; Qin, M.; Huang, H. Work stress among Chinese nurses to support Wuhan in fighting against COVID-19 epidemic. J. Nurs. Manag. 2020, 28, 1002–1009. [Google Scholar] [CrossRef] [PubMed]
  39. Bagnasco, A.; Zanini, M.; Hayter, M.; Catania, G.; Sasso, L. COVID 19-A message from Italy to the global nursing community. J. Adv. Nurs. 2020, 76, 2212–2214. [Google Scholar] [CrossRef]
  40. Cleveland Manchanda, E.C.; Sanky, C.; Appel, J.M. Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19. J. Racial Ethn. Health Disparities 2021, 8, 824–836. [Google Scholar] [CrossRef] [PubMed]
  41. Hugelius, K.; Harada, N.; Marutani, M. Consequences of visiting restrictions during the COVID-19 pandemic: An integrative review. Int. J. Nurs. Stud. 2021, 121, 104000. [Google Scholar] [CrossRef]
  42. Galanis, P.; Vraka, I.; Fragkou, D.; Bilali, A.; Kaitelidou, D. Nurses’ burnout and associated risk factors during the COVID-19 pandemic: A systematic review and meta-analysis. J. Adv. Nurs. 2021, 77, 3286–3302. [Google Scholar] [CrossRef]
  43. Babore, A.; Lombardi, L.; Viceconti, M.L.; Pignataro, S.; Marino, V.; Crudele, M.; Candelori, C.; Bramanti, S.M.; Trumello, C. Psychological effects of the COVID-2019 pandemic: Perceived stress and coping strategies among healthcare professionals. Psychiatry Res. 2020, 293, 113366. [Google Scholar] [CrossRef]
  44. Cai, H.; Tu, B.; Ma, J.; Chen, L.; Fu, L.; Jiang, Y.; Zhuang, Q. Psychological Impact and Coping Strategies of Frontline Medical Staff in Hunan Between January and March 2020 During the Outbreak of Coronavirus Disease 2019 (COVID-19) in Hubei, China. Med. Sci. Monit. 2020, 26, e924171-1. [Google Scholar]
  45. Huang, L.; Lei, W.; Xu, F.; Liu, H.; Yu, L. Emotional responses and coping strategies in nurses and nursing students during COVID-19 outbreak: A comparative study. PLoS ONE 2020, 15, e0237303. [Google Scholar] [CrossRef] [PubMed]
  46. Savitsky, B.; Findling, Y.; Ereli, A.; Hendel, T. Anxiety and coping strategies among nursing students during the COVID-19 pandemic. Nurse Educ. Pract. 2020, 46, 102809. [Google Scholar] [CrossRef] [PubMed]
  47. Javed, S.; Parveen, H. Adaptive coping strategies used by people during coronavirus. J. Educ. Health Promot. 2022, 10, 122. [Google Scholar] [CrossRef]
  48. Jubin, J.; Delmas, P.; Gilles, I.; Oulevey Bachmann, A.; Ortoleva Bucher, C. Protective Factors and Coping Styles Associated with Quality of Life during the COVID-19 Pandemic: A Comparison of Hospital or Care Institution and Private Practice Nurses. Int. J. Environ. Res. Public Health 2022, 19, 7112. [Google Scholar] [CrossRef] [PubMed]
  49. Sierakowska, M.; Doroszkiewicz, H. Stress coping strategies used by nurses during the COVID-19 pandemic. PeerJ 2022, 10, e13288. [Google Scholar] [CrossRef] [PubMed]
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